A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury.
Which statement by the adolescent indicates a need for further teaching?
I do my wheelchair exercises sitting in my chair.
I use a suppository every night to have a bowel movement.
I need to catheterize myself twice a day.
I carry a water bottle with me because I drink a lot of water.
The Correct Answer is C
Choice A rationale:
The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.
Choice B rationale:
The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:
The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.
Choice D rationale:
The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: B. Decreased deep tendon reflexes.
Choice A rationale: Wheezing is not typically associated with hyperkalemia. It is more commonly related to respiratory conditions.
Choice B rationale: Hyperkalemia can cause decreased deep tendon reflexes due to the effect of high potassium levels on nerve conduction and muscle function.
Choice C rationale: Hypoactive bowel sounds are not a common sign of hyperkalemia. They are more often associated with gastrointestinal issues.
Choice D rationale: Cerebral edema is not related to hyperkalemia. It is usually associated with conditions affecting the brain, such as trauma or infections.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Spinach is one of the most nutrient-dense vegetables. Just 1 cup (190 grams) of frozen spinach packs 12% of the DV for potassium. It’s also loaded with other nutrients. The same serving of frozen spinach contains 127% of the DV for vitamin A, 857% for vitamin K, 58% for folate, and 37% for magnesium.
Choice B rationale:
Potatoes are a staple food and are high in potassium. They are a versatile and filling food that can be included in a variety of dishes. Potatoes are also a good source of vitamin C and dietary fiber.
Choice C rationale:
Bananas are known as potassium-rich foods. A medium banana contains around 9% of the DV for this mineral. Most people consider it the go-to food to increase their potassium intake. However, bananas are not the only good source of potassium.
Choice D rationale:
Apples are a healthy choice and provide some potassium, but they are not as high in potassium as the other choices. Therefore, while apples are a good part of a balanced diet, they would not be the first recommendation for someone needing to increase their potassium intake.
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